Below is the recording from our webinar on Why Wellness Fails to control medical costs, recorded on April 13, 2016.

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The information included in this webinar is important. We know the drill – healthcare costs are crippling all of us. However, with the right approach to wellness and by implementing the right programs, we can have a significant impact!

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Links for further reading

One slide in the webinar had links to additional articles on our website(s). Here the links:

You’ve heard it before, maybe even believe it yourself:

“Eat the egg whites and trash the yolks!“

“Egg yolks are full of saturated fat and cholesterol – they are bad for you!”

The list goes on…

It’s hard not to get caught up in this line of thinking because it seems to be everywhere. After all, nearly every restaurant that serves breakfast has a “healthy breakfast option” that removes the yolks from the eggs.

Thinking this way is doing eggs all wrong. It’s time to stop the egg-yolk-phobia!

Unfortunately, fermented foods have largely disappeared from the Western diet, much to the detriment of our health and economy. Fermented foods are a powerful aid to digestion and a protection against disease. And because fermentation is, by nature, an artisanal process, the disappearance of fermented foods has hastened the centralization and industrialization of our food supply, to the detriment of small farms and local economies.

There are many things you can learn to ferment from this book, like making beer, wine or vinegar. There are also the standard recipes, like sauerkraut, dill pickles, yogurt, kimchi and kombucha. But the real benefit of this book is learning the technique of fermenting.

For example, it is rather simple to make sauerkraut. You need cabbage, salt and a couple of kitchen tools. That’s pretty much it. Katz takes three pages to explain and discuss this topic. Reading this book, you feel how much he enjoys preparing foods this way.

And if you take the time to read and absorb what he has written, you appreciate it more.

Is Exercise More Difficult with Type 2 Diabetes?

We will answer this question shortly.

But first, when talking about whether exercise is more “difficult” for type 2 diabetics, the question is really referencing exercise intensity. There are a number of ways to measure/monitor exercise intensity. We prefer to use Ratings of Perceived Exertion (RPE).

The question refers to a scenario like this:

Given two individuals where everything is the same (age, gender, height, weight, etc…) when performing the same type of exercise, is it more difficult for the type 2 diabetic?

The answer to this question: Yes (in general)1

To illustrate, let’s say the exercise we referred to above is walking at 3 mph. The typical non-diabetic might rate the intensity of this activity at a 3 or 4 on a 10-point RPE scale, while the typical type 2 diabetic might rate it a 5 or 6 on the same scale.

Since RPE is a measure of intensity and 5 or 6 is higher than 3 or 4, we would have to say that, in general, type 2 diabetics have more difficulty with the same activity than non-diabetics.

Why is exercise harder for Type 2 Diabetics?

Look no further than resting metabolism. Metabolically unhealthy (which is what type 2 diabetics are) have a higher respiratory quotient at rest when compared to metabolically healthy individuals. This means type 2 diabetics are using a larger proportion of carbohydrates as a substrate to produce energy. Further, substrate utilization predicts intensity: The more carbohydrates, the higher the intensity.

For type 2 diabetics, this means that even at rest they are producing energy differently than non-type 2 diabetics. And when we change the intensity, like walking at 3 mph for example, this relationship holds true. So they continue to operate at a higher intensity, which is what makes exercise more difficult for type 2 diabetics.

If this is the case, how should we approach exercise and exercise intensity for type 2 diabetics?

Type 2 Diabetics and Exercise

From a metabolic perspective, type 2 diabetics operate at a higher intensity level in comparable exercise because their ability to use fat as a substrate to produce energy has been compromised. (See this for an example). In other words, the average type 2 diabetic has difficulty in using fat to produce energy.

This difficulty in using fat to produce energy makes it harder for type 2 diabetics to lose weight.

This should be addressed first.

Improving metabolic flexibility in type 2 diabetics

In the literature and even within both The Academy and the HPI Diabetes Academy, we refer to this as metabolic flexibility: The ability of the metabolism to switch between substrates (carbohydrates or fats) to produce energy. For someone lacking metabolic flexibility, their ability to switch is compromised. Since type 2 diabetics have difficulty in using fat to produce energy, their metabolic flexibility is compromised.

So the first objective should be to “un-compromise” them by improving metabolic flexibility.

The two best approaches to fixing this are with food and exercise. Since this article is about exercise, we will omit the food part.

We only have two recommendations for exercise: low-intensity and/or high-intensity. Both are effective for different reasons.

Low intensity is effective because it forces the body to get better at using/burning fat during the exercise session. There are a couple of caveats, however:

The intensity must be lower than normal, due to the compromised ability to burn fat.

To be most effective, duration must be longer than 30 minutes – the longer the better. As it takes time for the body to fully get into a fat burning mode, shorter duration activities are not as helpful.

High-intensity exercise is effective because it helps improve the body’s ability to burn fat outside of the session. Earlier, we mentioned that type 2 diabetics have a higher respiratory quotient at rest, which means they are using a higher proportion of carbohydrates to produce energy. As the body adapts to high-intensity exercise, it starts fixing this problem. The end result is a lower respiratory quotient, which means the body is using a larger percentage of fat to produce energy at rest.

On a related note, this is why we aren’t big fans of jogging for most people until they get to a point where metabolic flexibility has improved.

Yes, exercise is more difficult for type 2 diabetics

But this problem can be fixed with an appropriate exercise prescription, one that improves the body’s ability to burn fat during exercise and at rest.

This will result in the increased ability to perform comparable exercise at a lower intensity.

Endnotes

1We say in general, because there are always exceptions and this refers to the average.

While heart rate (HR) is a popular way to measure exercise intensity, we prefer Ratings of Perceived Exertion (RPE) and will explain why in this post.

When using HR, you workout at some percentage of Max HR; for example between 50-60% or 70-80% of Max HR. The usual way to determine Max HR is by subtracting your age from 220 (Max HR = 220 – age). Once you know Max HR, the upper and lower ends of your HR range can easily be determined.

This seems simple and straightforward but technology doesn’t always get it right. For example, there is a class action lawsuit against Fitbit, claiming their technology and/or algorithms are inaccurate. This can have serious consequences for the user, particularly at the higher end of intensity.

We prefer RPE

RPE stands for Ratings of Perceived Exertion and the key word here is “perceived.”

The “perception” of how hard you are exercising is important for evaluating the overall intensity of the workout. And it is probably more accurate than measuring heart rate only. For example, let’s say you were working out hard – near your maximum capacity. You would certainly “feel” like you were working hard, but if you were using a HR monitor to determine intensity and this HR monitor consistently under-reported your HR, you might think you weren’t working hard enough. This would be in spite of how you “feel” and might compel you to try or push yourself harder. This could lead to a dangerous situation.

The RPE scale takes this into account.

Using numbers on a scale and descriptors for how you should feel at various levels of intensity, a user can accurately identify exercise intensity.

This is probably the most popular RPE scale. If you’ve ever taken a treadmill test – either for a research project in college (or graduate school) or at the cardiologist office, you probably saw something like this.

Notice on the left there are numbers for rating the intensity of exercise and descriptors on the right for helping you pick the most appropriate rating. This is the perception part we refer to and think is important.

While the ratings correlate with HR, they are not 100% accurate.

In both The Academy and HPI Diabetes Academy, we use a slightly different RPE scale – the CR-10 Scale.

We use this version for a couple of reasons:

One, it starts at zero. Notice the scale above starts at 6. We prefer a scale that starts at zero so we have a better anchor point for a resting intensity.

Second, it is much more convenient than any type of HR monitor.

Once a person is comfortable with using the scale, nothing else is needed.

To finish this up, the green areas indicate how we prescribe exercise for those in our programs. We recommend either “light” or “hard” exercise and prescribe intensity using this scale. For example, light workouts should have an RPE of 2-5 while hard workouts should have an RPE of 7+. We skip “6” on purpose and it’s not because there is no descriptor. There is a metabolic reason.

Beyond the two points mentioned above, this also allows our users a lot of flexibility. They can do any activity they’d like, as long as it meets the RPE criteria. This means they aren’t restricted to walking, jogging, cycling or any activity where measuring HR might be problematic (like swimming).

Getting The Academy at your place of business

Below we describe the typical process of how a company gets The Academy implemented with their employees.

This is important for a few reasons but one of these is most important.

It is likely that our approach to this is very different than what you are used to seeing. Some explanation can be helpful.

Step 1: Discuss The Academy

This is a simple but necessary step. Everyone involved, from those enrolled to those making the decisions should understand how this works. We cover all of this during Step 1.

For example, The Academy is geared to helping specific groups of people: Those at risk or diagnosed with any combination of the following:

Type 2 diabetes

High blood pressure

High cholesterol

The “at risk” includes those with a family history of these conditions or those diagnosed as “pre-“, pre-diabetic or pre-hypertensive.

We also discuss the 12 Modules and how they are delivered – in-person (best outcomes), online or some combination.

Our preferred method of doing Step 1 is a 30-minute meeting/presentation, with key people in attendance, including: Someone from the executive leadership team, preferably a person involved with the financial aspects of the company (CFO, Controller); someone in a leadership position within HR and the person in charge of benefits. Additionally, anyone else involved in the decision-making or implementation process is also helpful.

Step 2: Is there a good fit?

Once we’ve completed the above, the next step is to determine if there is a good fit.

This is a simple process and involves us looking at some of your current healthcare spending. The most important things for us to evaluate include:

Rates of the above mentioned conditions within your employee population.

The number of prescriptions for these conditions.

Dollars spent on these conditions.

We evaluate aggregate information, so the total percentage of those with diabetes, high blood pressure or high cholesterol is perfect. As for the last two bullet points, the typical Top 25 table of prescription drugs will usually suffice.

So how do we determine fit?

This part is simple.

We take your information, apply our typical results and tell you what to expect in outcomes.

It is simple because we give you two numbers: 1) how much our services would cost and 2) how much we expect to save your company. You compare and then make a decision.

See? Simple!

Step 3: Implementation

If we have all determined there is a good fit, the next step involves working out the details for implementation.

The very first decision that needs to be made is this: “How many people do you want to enroll in The Academy?”

Some companies are little hesitant to implement a company-wide strategy like The Academy right off the bat. We understand. So we offer a Pilot Program, where The Academy gets implemented with a defined number of employees. We refer to this as the “Target Enrollment” and once identified, we then start with phase 2 of implementation.

This involves the following: deposit, dates and recruitment.

The deposit is typically 15% of the total invoice. This allows us to get started on the backend. It also allows you to reserve certain dates/times for the sessions, if you’d like.

There are several dates that need to be identified: information sessions, measurement sessions, start date, etc…

Recruitment is done mainly through emails (which we provide) and the information sessions. We also need to define who is allowed to enroll. The best approach we have seen is allowing anyone to enroll.

There are more details, for sure. But this covers the gist.

Step 4: Off and running

Once all of the above is complete – everyone enrolled, measured and entered into our system, we start with Module 1.

At the time of Module 1, we also submit the final invoice, which is adjusted for the deposit and any discrepancy from the Target Number.

Somewhere around Module 2, we give you a summary report of those enrolled. This report is descriptive and includes aggregate information on height, weight, body composition, health status, targeted medications and more.

That’s our process

It gives you some idea of how it typically works.

If you are interested in learning more or would like to know if The Academy might be a good fit for your company, reach out to us. We are be more than happy to talk with you.

Reference Resources

Eating on the Wild Side by Jo Robinson

There is so much to learn from this book, it’s hard to pick where to start. If learning about foods, preparing them yourself and doing little things to improve the health impact of a food are important, this book is for you.

Charcuterie by Ruhlman and Polcyn

The fine art and science of curing just about any meat in any way imaginable!

Bones by Jennifer McLagan

Your grandparents can probably relate to many things in this book. And there is a reason they didn’t get sick. Bones are healthy. In this book, there are many ways to prepare bones to extract the goodness from them.

Ruhlman’s Twenty by Ruhlman

The 20 refers to 20 1-word techniques, like think or butter or sauté or sauce. With these 20 techniques, there are 100 recipes.

Odd Bits by Jennifer McLagan

From McLagan about this book: “Most of the meat we eat – the tenderloins, racks, steaks, legs and chops – is only a small percentage of the animal carcass.”

Well, I’m not interested in these cuts and you won’t find them here. This book is about the rest of the animal: The pieces we once enjoyed and relished but no longer bother with.

Textbook of Medical Physiology by Guyton

At one point, this was the number one selling textbook on human physiology in the country. I didn’t know a single graduate student that didn’t have a copy! Whether or not it is still the number one seller, I don’t know. But this book is invaluable as a reference. Plainly written, thorough and easy to understand.

Books on Sports / Exercise Physiology (several of them)

This is the “in motion” or “during exercise” equivalent to the Guyton textbook above.

Countless articles through medical/science/research journals

There is always a stack of these to go through, highlight and either write about or decide if we should make changes to our recommendations.

Meet Kathryn!

To be the HPI Academy Member of the Year, you have to exhibit more than just results. Kathryn did that in a big way!

Kathryn did not miss a single session. She was always there. Smiling. Happy. Ready to listen and ask questions. And she asked great questions, which meant she was paying attention!

Her excitement and enthusiasm rubbed off on the others.

It was all of this that made her an easy selection for Member of the Year.

Congratulations, Kathryn! This is well-deserved.

Her Results

While this is about more than results, here are hers.

Before and after pics.

That smile never disappears.

Some of the details!

In 6 months she:

Lost 30 pounds

Lost a total of 13.75 inches

Saw her blood pressure drop nearly 20 points

And most importantly, nearly 100% of the weight she lost was fat weight

Great numbers but there is more!

The Interview

We ask each of our members of the year a series of questions. Here are some of the questions we asked Kathryn and her responses.

What did you like about The Academy?

My experience with the Academy was a delightful experience. I was a skeptic at first because I am very self-conscious when it comes to my weight. But I must tell you that all of that dissipated after the first Module.

Do you have suggestions on how we can make The Academy better?

I have no complaints about he Academy at all. It is very easy to follow if you have the intent in your mind to make constructive changes in your life style.

The literature presented in each module was informative and easy to understand. The facilitator was “excellent”. He has been deemed my “five flavor lifesaver for life”. I will continue to work on my health initiative.

It’s a life saver.

Where do you have your plaque displayed?

At the present time, my plaque is proudly displayed here in my office. I want to rub it in on my coworkers. I have them bow when I enter the room, and have been called “Ms. HPI” on several occasions. I wear the title proudly.

Special shout out to Dr. Brian Sekula.

He’s my hero!!!

Excellent Stuff!

To have someone say what we did was a “life saver” doesn’t get much better.

We don’t take any of this lightly. It is very gratifying that we were able to play a role in guiding Kathryn to this outcome.

So we said there was more than just numbers. There was. We could not be more happy for Kathryn or proud to have her as our Member of the Year.

The last thing we will leave you with is Kathryn receiving her plaque. We did this in front of her co-workers. They were also very happy for her!

Congratulations Kathryn on a job well-done and an award well-deserved!

Dinner with the husband, the shakes and metabolic flexibility

Have you ever experienced your hands starting to shake a little when you are hungry? When that happens, it’s time to get something to eat. Right?

Maybe.

Maybe not. This post is about that exact issue.

We had a great question this week from a member of The Academy.

About 3-4 hours after eating a meal, she can feel hunger setting in and her hands start to shake a little.

For her, this typically happens late afternoon / early evening. One option she has is to eat something (more on this later). But she doesn’t really want to do that. She likes having dinner with her husband and doesn’t want to mess that up!

She was following our recommendations and wondered if there was anything she could do.

Access and Metabolic Flexibility

There are many aspects to how and why your body gets hungry but since she was following our recommendations and experiencing less hunger overall, it didn’t sound like it was a food related issue. It sounded like an access and metabolic flexibility issue.

Here is a textbook definition of metabolic flexibility? In verbiage you might not find in an endocrinology journal, metabolic flexibility is defined as the ease in which your body can switch between burning carbohydrates and/or fats to produce energy. The less flexible your metabolism is, the harder it is to switch. Most people with poor metabolic flexibility are good at burning carbohydrates, which means burning fat is hard. This means that losing weight (specifically fat tissue) can be difficult.

When we eat a meal, the food provides a rush of energy that comes from the macronnutrients (carbohydrates, fats and proteins) and micronutrients (vitamins, minerals, etc…). Over time, this rush decreases and eventually returns to pre-meal levels. During this period of time, our body has access to a lot of potential energy. So we don’t feel hungry. But as the access to potential energy diminishes, we get closer to being hungry.

This is why metabolic flexibility and access to energy are tied together. Here is the situation for most adults: Your body has a lot of fat to lose but because your metabolic flexibility is poor, you can’t access it. This is the “access problem” we discuss in The Academy. When that rush of energy from the food you’ve eaten is gone, your body needs more. And if it can’t access fat stores, it sends hunger signals. Then you get hungry. Then you eat.

(This cycle starts with weight gain as a result of decreasing insulin sensitivity. As insulin sensitivity continues to decrease, pre-diabetes and then full-blown diabetes are on the horizon.)

Can we fix this problem?

Let’s return to our question. She was following our recommendations. In general, her hunger levels were better. This signals an improving metabolic flexibility. But, it wasn’t improved enough to keep her from getting the shakes or allowing her the ability to wait and have dinner with her husband.

To answer her question directly, the response was “Yes” there is something she can do!

At the beginning of this post, one of the things we mentioned that she could do was eat something. This would solve the problem because the “food rush” would provide a lot of potential energy, which would mean her body would stop trying to “access” the fat tissue. So eating food would fix it and eliminate the shakes.

Not practical for two reasons:

The first is personal. She wants to have dinner with her husband. Eating would spoil that. So it’s not a good option.

This one is from our perspective. Eating food when access is low only fixes the “lack of energy” problem and does nothing to address the access to energy problem. It just “kicks the can down the road.” She will eat. The shakes will stop. But as soon as the “rush” is over, she will be hungry again. Not a practical long term solution.

Ok, so what to do?

We have diagnosed this as an access and metabolic flexibility issue. From above, we noted these two things were tied together. If our diagnoses is accurate, then improving one should improve the other.

Earlier we defined poor metabolic flexibility. Optimal metabolic flexibility, conversely, means our body can easily switch between burning fats and carbohydrates to produce energy. If our metabolic flexibility is optimal, we can “access” the fat stores. This can eliminate the access problem and decrease hunger (and in this case, the shakes too!).

The prescription

We told her the following:

When the shakes set in and you are not ready to eat, take a walk.

Walking forces your body to burn fat, improving metabolic flexibility. In turn, this will help eliminate the access problem.

We suggested a 10-15 minute walk.

She went above and beyond.

She walked until the shakes disappeared.

It took 22 minutes!

Problem solved.

The shakes went away.

The access problem was gone.*

Most importantly, she was able to have dinner with her husband!

We are happy for her and glad to play a small role in her finding success!

*The access problem isn’t gone completely. But it is better. Most importantly, it’s better enough for her not to be so hungry that it might mess up dinner with her husband!

UPDATE – July 2017Calm.com has made some changes to their website. It is still free but you need to create an account to use the website. You can log in with your Facebook account or create a separate one.

Many of the features discussed below are still available (and still free) once you create an account. However, they also offer a membership (with different options) for additional relaxation tools and sounds. Once you create your account, you can easily see what is available free and what requires a membership.

What is Calm dot com?

To begin with, it is one of our favorites!

As you might gather from its name, it can help you calm down, relax or de-stress.

It does this by playing relaxing sounds through your computer. There are 25 different sounds, ranging from the sound of the ocean, to rain, nature sounds and more. Also…each of the sounds has an animated image that compliments the sound.

In this post we will give you some pointers on how to take full advantage of it.

Visiting the website

As soon as you visit the website, the default sound and image are loaded. The default sound seems to be a combination of wind, birds, rain and other nature sounds. The image shows tree-covered mountains in the foreground and snow-capped mountains in the background. There is a slow moving river between the mountains in the foreground. Outstanding!

The image at the top of this post shows what you see when the site is loaded. The image below focuses on the left-hand side of the page. There are two things to point out here. First, you can download the app to any Apple or Google portable device. Second, you can take a meditation break! Just click one of the icons for however long your meditation break needs to be.

If/When you need a meditation break and after you select a time option, you are then given two options for type of meditation (see image below): Guided (on the left) or Timer Only (on the right). What’s the difference? In the guided meditation, narration takes you through the process. In the timer only, you take yourself through the process. If you are new to meditation, we suggest the guided one to get started.

Once you’ve made your choice, you are ready to begin! Click “I’m ready” to get started. Note: We highly recommend the headphones, particularly if you are at the office. It limits your distractions.

Using it daily

While we think the meditations are excellent, the real benefit of calm.com comes from daily use. Just load the site, select your sound, adjust the volume and let it play in the background all day long. Use the meditations when things are stressful or during your busy times, so you can relax, focus and get more done.

There are 25 different sounds it can play. To play something different, move your mouse to the bottom-right of the screen, click the icon that looks like a mountain (right next to the volume icon) and select from the pop-up. See the image below.

Our favorite one at the moment is rain – right in the middle of the top row. The image below is what is loaded when this sound plays. The animation in this image shows the tree limb moving slightly and slowly from the rain, you can watch rain drops falling off the limbs and leaves and you can see the rain falling in the background.

Just sitting, staring and listening for even 2 minutes will calm you down!

One of our favorite tools

It should be clear by now why this is one of our favorite tools for managing stress.

We suggest you start loading this site on your computer at work before doing anything – before coffee, before checking email, voice mail, etc… Watch the reaction of people when they walk into your office: “It sounds like it’s raining in here!” and you can excitedly spread the good news to them.

Give this a shot, load it on your phone or tablet too, and let us know how it works for you.